Understanding Medicare Coverage for In-Home Care

Navigating the complexities of Medicare can be daunting. With its four distinct parts and supplemental insurance plans sold by private companies, understanding what is and isn't covered can be challenging. This blog aims to clarify the specific types of in-home care not covered by Medicare, especially important for those caring for homebound seniors after hospitalization or those with chronic conditions requiring ongoing care.

Key Points to Understand Medicare Coverage

1. Medicare’s Structure: Medicare is divided into four parts – A, B, C, and D. Parts A and B cover some home care services, while Part C includes additional coverage at extra cost to consumers. This discussion will focus on Parts A and B.
2. Types of Home Care: Home care can be classified into medical (home health care) and non-medical care.

The Intricacies of Medicare Parts

To understand what Medicare does not cover, it is crucial to delve deeper into the specifics of Medicare Parts A, B, C, and D.

Medicare Part A: Hospital Insurance

Medicare Part A primarily provides coverage for inpatient hospital care, skilled nursing facility care, hospice care, and limited home health care. Part A is often referred to as hospital insurance. Here’s a detailed look at what it covers and its limitations:

1. Inpatient Hospital Care: Part A covers the cost of a semi-private room, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. It does not cover private-duty nursing, a television or telephone in your room (if there is a separate charge for these items), or personal care items like razors or slipper socks.
2. Skilled Nursing Facility (SNF) Care: Part A covers care in a skilled nursing facility for a limited time if it’s following a hospital stay of at least three days, provided it is within 30 days of the hospital stay and you need skilled care such as physical therapy or skilled nursing care.
3. Home Health Care: This includes part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, continued occupational therapy, and more. However, the patient must be homebound, and the care must be medically necessary.
4. Hospice Care: For those with a terminal illness, Part A covers hospice care if the patient has a life expectancy of six months or less. This care includes drugs for symptom control and pain relief, medical and support services, grief counseling, and other services not otherwise covered by Medicare.

Medicare Part B: Medical Insurance

Medicare Part B covers outpatient care, preventive services, certain doctors' services, outpatient hospital services, durable medical equipment, and some home health care. Part B is often referred to as medical insurance. Here’s a detailed look at its coverage and limitations:

1. Outpatient Care: Includes services and supplies such as physician visits, lab tests, surgeries, and home health care when medically necessary.
2. Preventive Services: Services such as flu shots, screenings, and annual wellness visits are covered to help prevent illnesses.
3. Durable Medical Equipment (DME): Items such as wheelchairs, walkers, and hospital beds are covered if they are prescribed by a doctor for use in the home.
4. Home Health Care: Covers medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, and continued occupational therapy. To qualify, the care must be certified by a doctor, the patient must be homebound, and the services must be provided by a Medicare-certified home health agency.

Medicare Part C: Medicare Advantage

Medicare Part C, or Medicare Advantage, is an alternative to Original Medicare (Parts A and B) offered by private insurance companies approved by Medicare. These plans often include additional benefits such as dental, vision, hearing, and wellness programs. They may also cover prescription drugs.

1. Additional Coverage: Part C plans may offer extra benefits not covered by Original Medicare, such as routine dental and vision care, fitness memberships, and other health-related benefits. 
2. Cost Structure: Part C plans typically have different cost structures, such as varying premiums, copayments, and out-of-pocket maximums. Enrollees must still pay the Part B premium.
3. Provider Networks: These plans often have networks of doctors and hospitals. Out-of-network services may cost more or may not be covered.

Medicare Part D: Prescription Drug Coverage

Medicare Part D provides coverage for prescription drugs through plans offered by private insurance companies. These plans help cover the cost of prescription drugs, providing protection against high out-of-pocket costs.

1. Formularies: Each Part D plan has its own list of covered drugs, known as a formulary. Plans may place drugs into different tiers, with different costs associated with each tier.
2. Coverage Gap: Part D includes a coverage gap (also known as the “donut hole”), where there is a temporary limit on what the drug plan will cover for drugs. After spending a certain amount out-of-pocket, catastrophic coverage begins, and the plan covers most drug costs.

Medicare and In-Home Caregivers

Medicare provides limited coverage for in-home caregivers. This coverage depends on the senior's care needs as defined by their care plan, which is created by a physician or nurse following discharge from a hospital or Skilled Nursing Facility (SNF). Often, the care needs exceed what Medicare covers.

Conditions for Medicare Coverage

Medicare may cover part-time non-medical in-home caregivers, but only if they work alongside skilled care providers such as nurses or therapists. This care must be medically necessary and prescribed by a doctor.

1. Part-Time or Intermittent Care: Medicare defines part-time or intermittent care as skilled nursing care provided fewer than seven days each week or less than eight hours each day over a period of 21 days (or less).
2. Medical Necessity: The care must be deemed medically necessary and certified by a doctor. For example, it could include physical therapy after surgery or nursing care for wound management.
3. Homebound Status: The patient must be homebound, meaning they have difficulty leaving home without assistance due to illness or injury.
4. Skilled Care Requirement: The patient must need skilled care on an intermittent basis, which is provided by a Medicare-certified home health agency.

Non-Medical In-Home Care and Activities of Daily Living (ADLs)

Medicare does not cover non-medical in-home care or assistance with ADLs unless it is part of a broader care plan that includes skilled medical services.

1. Activities of Daily Living (ADLs): These include bathing, dressing, eating, using the bathroom, transferring (e.g., moving from a bed to a chair), and maintaining continence.
2. Non-Medical Care: This type of care, often provided by home health aides or personal care aides, includes companionship, meal preparation, light housekeeping, and medication reminders. These services are essential for many seniors to live independently but are not covered by Medicare Parts A or B.

The Difference Between Medicare Part A and Part B in Home Health Care

Medicare Part A Home Health Coverage

1. Hospital Discharge Requirement: To receive home health care under Part A, the patient must be discharged from a hospital or SNF after at least three consecutive days of inpatient care.
2. Initial Coverage Period: Medicare Part A covers up to 100 days of home health care if the services begin within 14 days of discharge.
3. Limited Coverage: Part A’s coverage is often limited to intermittent skilled nursing care and therapy services. It does not cover long-term care or non-medical services. 

Medicare Part B Home Health Coverage

1. Ongoing Medical Needs: Part B covers home health care for patients with ongoing medical needs that require intermittent skilled care.
2. Outpatient Services: Includes doctor visits, medical supplies, and preventive services, which are often essential for managing chronic conditions at home.
3. 3.Limitations: Like Part A, Part B does not cover 24-hour home care, meal delivery, or assistance with ADLs unless provided alongside skilled care.

Coverage for Caregivers Under Medicare Part B

Medicare Part B’s coverage for in-home caregivers is minimal. Typically, it covers up to 8 hours per day or 28 hours per week and only in conjunction with other skilled care. Therefore, Medicare-covered caregivers are usually working with another skilled care provider.

Post-Hospitalization Home Health Care

Medicare Part A may cover intermittent home care following hospitalization if the care plan includes skilled services like nursing or therapy. This coverage applies within 14 days of discharge from a hospital or SNF and lasts up to 100 days. Post-100 days, any covered care falls under Medicare Part B. Regardless of coverage type, hours are usually limited to 28 per week.

Eligibility Requirements for Home Health Care

1. Homebound Status: The patient must be homebound, meaning they have difficulty leaving home without assistance due to illness or injury.
2. Skilled Care Need: The patient must require skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy.
3. Doctor’s Certification: The care must be certified by a doctor who establishes a plan of care and reviews it regularly.
4. Medicare-Certified Agency: The services must be provided by a Medicare-certified home health agency.

In-Home Nursing Care Under Medicare

Medicare Part A covers some home health care, including nursing, following a hospital or SNF stay of at least three consecutive days. This coverage is limited and requires meeting specific eligibility criteria. Services must begin within 14 days of discharge.

Whether your loved one needs assistance only a few hours a week or around-the-clock, our team is happy to help! Call (508) 802-5271 to learn more about the transition care services offered through ComForCare Home Care (Marlborough, MA).